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Complications and Survival Rates of Inlays and Onlays Vs Complete Coverage Restorations. Georgia I. Vagropoulou. 2018. J Oral Rehabil
Complications and Survival Rates of Inlays and Onlays Vs Complete Coverage Restorations. Georgia I. Vagropoulou. 2018. J Oral Rehabil
DOI: 10.1111/joor.12695
REVIEW
1
Department of Prosthodontics, Division
of Graduate Prosthodontics, School Summary
of Dentistry, Aristotle University of Objective: The aim of this study was to identify if different types of indirect restora-
Thessaloniki, Thessaloniki, Greece
2
tions used for single teeth had different biological and technical complications, as
School of Dentistry, Aristotle University of
Thessaloniki, Thessaloniki, Greece well as survival rates.
3
Department of Restorative Sciences Method: An electronic search was performed in various electronic databases to
and Biomaterials, Division of Graduate
identify articles, published between 1980 and 2017. The search terms were catego-
Prosthodontics, Henry M Goldman School of
Dental Medicine, Boston University, Boston, rised into 4 groups: inlay, onlay, inlay/onlay and crown. Manual searches of published
Massachusetts
full-text articles and related reviews were also performed.
4
Department of Prosthodontics, Division
of Graduate and Postgraduate Results: A total number of 2849 papers were retrieved initially. After a detailed as-
Prosthodontics, School of Dental sessment for eligibility, 9 studies were selected for inclusion. The heterogeneity of
Medicine, Tufts University, Boston,
Massachusetts the studies did allow neither a meta-analysis nor any meaningful comparison be-
tween types of restorations or materials. Only some pooling was performed for rep-
Correspondence: Konstantinos Michalakis,
Department of Prosthodontics, Division resentative reasons. The mean survival rate of inlays was 90.89%, while for onlays
of Graduate Prosthodontics, School and crowns it was 93.50% and 95.38%, respectively. For the fourth study group,
of Dentistry, Aristotle University of
Thessaloniki, University Campus, consisting of both inlays and onlays, the survival rate was found to be 99.43%.
Thessaloniki 54124, Greece (kmichalakis@ Statistical analysis demonstrated caries to be the main biological complication for all
hotmail.com).
types of restorations, followed by a root and/or tooth fracture incidence (11.34%)
and endodontic incidence. Ceramic fractures represented the most common techni-
cal complication, followed by loss of retention and porcelain chipping.
Conclusion: The 5-year survival rate for crowns and inlays/onlays is very high, ex-
ceeding 90%. An association between the kind of complications and different types
of restorations could not be established. Nevertheless, a relatively high failure rate
due to caries and ceramic fractures was noted.
KEYWORDS
complications, crown, inlay, onlay, survival rates, tooth
J Oral Rehabil. 2018;45:903–920. © 2018 John Wiley & Sons Ltd | 903
wileyonlinelibrary.com/journal/joor
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904 VAGROPOULOU et al.
F I G U R E 1 PICO question
VAGROPOULOU et al. |
907
to identify the final articles which would be used for this systematic the diagrams existing in each study was performed by all 3 review-
review. The 2 principal investigators (GV, GK) came to an agreement ers independently, using the rule of three. Thus, numeric data were
on the articles which would be included in this systematic review. extracted from each study included in this review. In those cases
Following that, a final control was conducted by the third reviewer that data were insufficient the authors of the articles were con-
(SV), who assessed each one of the selected studies for its eligibility, tacted by means of email. Survival was defined as the restoration
according to the set criteria. All 3 reviewers agreed on the selection of remaining in situ for the observation period with or without modi-
the articles to be included (Figure 2, Table 1). fications.45-53 The analysis of the technical complications included
chipping, fracture or crack of the ceramic, loss of retention, core fail-
ure and marginal integrity. The analysis of the biological complica-
2.4 | Data extraction
tions included caries, tooth fracture, root fracture, hypersensitivity
Information on the survival rates and on the biological and tech- and pulpitis or other damage of the pulp, which led to endodontic
nical complications of the restorations was extracted from the in- treatment. The following parameters were studied by the 2 review-
cluded studies. The number of events and the corresponding total ers (GV and GK) and associated data were retrieved: setting; lead
time of service of restorations were calculated. An assessment of author; year of publication; journal of publication; study design; total
TA B L E 1 Detailed information of the 9 studies included in the present systematic review
|
Gender
908
Authors Year Journal Study design Men Women Age Setting Evaluation criteria Inclusion criteria
Barnes et al 2010 AJD Prospective clinical trial N.m. N.m. N.m. University Modified USPHS N.m.
Djiken et al 2010 ADM Prospective clinical trial 46/121 75/121 26-81 Private/University Modified USPHS N.m.
Riech et al 2004 JADA Prospective clinical trial 18/26 8/26 18-77 University USPHS/Modified USPHS Extensive tooth destruction
Sulaiman et al 2015 JPD Retrospective Study N.m. N.m. N.m. Private N.m. N.m.
Fabbri et al 2014 Int J PRD Retrospective Study 143/312 169/312 19-71 Private/University Modified CDA Good oral health, Sample
including both vital and
non-vital teeth, Natural teeth
in the opposing dentition
Beier et al 2012 IJP Retrospective Study 120/302 182/302 33.3-59.65 University Modified CDA Periodontal Health
Donovan et al 2004 JERD Retrospective Study 39/114 75/114 31-91 Private N.m. N.m.
Kelly et al 2004 BDJ Retrospective Study N.m. N.m. 28.44-52.38 Private N.m. N.m.
Heckland et al 2003 IJP Retrospective Study N.m. N.m. N.m. Private N.m. N.m.
Location of restorations
Authors Inlays Onlays Crowns Inlays Onlays Crowns Inlays Onlays Crowns Inlays Onlays Crowns
Barnes et al Leucite reinforced ceramic(all restorations) Dual cure resin cement
Djiken et al Leucite reinforced ceramic(all restorations) 1. Chemically cured resin
2. Dual curing composite system
(Continues)
VAGROPOULOU et al.
TA B L E 1 (Continued)
Riech et al 1. Feldspathic ceramics(number of restorations not mentioned) 1. Dual cure resin cement
2. Leucite reinforced ceramics(number of restorations not mentioned) 2. Dual curing composite system
Sulaiman et al 1. Lithium disilicate monothic ceramic(1.093/1.093inlays-onlays, 11.603/15.765 crowns) N.m.
2. Lithium disilicate layered ceramic(4.162/15.765 crowns)
Fabbri et al 1. Lithium disilicate monolithic ceramic(46/62 onlays-154/428 crowns) 1. Dual cure resin cement
2. Lithium disilicate layered ceramic(16/62 onlays-274/428 crowns) 2. Flowable composite resin
3. Dual curing composite system
Beier et al Silicate ceramic 1. Dual cure resin cement(6/334 inlays-20/470 crowns)
2. Chemically cured resin(5/334 inlays-1/213 onlays-29/470 crowns)
3. Dual curing composite system(323/334 inlays-212/213 onlays-421/470
crowns)
Donovan et al Cast gold(all restorations) Zinc phosphate
Kelly et al 1. Feldspathic ceramic(18/323) N.m.
2. Ceramometal (212/323 crowns)
3. Cast gold(93/323 crowns-22/22 onlays)
Hekland et al 1. Feld spathic ceramic(675/1.544 inlays-onlays, 487/746 crowns) N.m.
2. Leucite reinforced ceramic(869/1.544 inlays-onlays, 166/746 crowns)
3. Lithium disilicate ceramic(93/746 crowns)
Total number of survived units Total number of failed units Type of failures
Mean follow
Authors up time/range Inlays Onlays Crowns Inlays Onlays Crowns Biological complications Technical complications
Barnes et al 36/6-36 0/1 (dropout at 15/16 35/36 0/1 (dropout 1/16 1/36 Root-tooth fracture Ceramic fracture
24 mo) at 24 mo) ● 1 crown ● 1 onlay
Djiken et al 180/30-42 19/29 72/88 65/84 10/29 16/88 19/84 N.m. N.m
Riech et al 36/30-42 21/22 20/20 1/22 0/20 Root-tooth fracture
● 1 onlay
(Continues)
|
909
910 | VAGROPOULOU et al.
Chipping-marginal integrity
dependently by 3 authors (GV, GK, SV) using data extraction forms
Technical complications
● 2/37 crowns
cussion which led to a consensus between the 3 authors. Data pleth-
● 2/21 inlays
● 9/21 inlays
● 1/5 onlays
● 1/5 onlays
ora and space saving issues led to the categorisation of the most
informative parameters only (lead author; year of publication; jour-
N.m.
N.m.
N.m.
nal of publication; study design; gender and age of patient; setting;
evaluation criteria; inclusion criteria; total number of restorations;
Biological complications
● 1/37 crowns vived units; total number of failed units; type of failures) in the tables
● 3/37 crowns
● 5/37 crowns
Type of failures
● 1/21 inlays
● 7/21 inlays
● 1/5 onlays
● 1/5 onlays
● 2/37
● 1/5
Caries
N.m.
N.m.
N.m.
3 | A N A LYS I S O F S T U D I E S
Crowns
12/746
68/323
14/355
37/470
22/22
5/213
6/197
3/1544
21/334
Inlays
SR) or the total number of failures (for FR). Neyeloff et al 54 proposed
341/355
433/470
255/323
Crowns
191/197
Onlays
55,56
ological frame of the random effects model of meta-analysis
313/334
614/644
Inlays
N/m/12-480
Mean follow
Hekland et al
Kelly et al
no evidence relative to the normality of the distribution of the effect the 9 studies included in this review were retrospective,45-50 while
size indices (SR or FR) used in the current analyses. The heteroge- the remaining 3 were prospective.51-53 Four out of the 9 included
neity of studies was assessed with the Q test at significance level studies provided data from records of patients who had been treated
P ≤ 0.10 [31] in order to increase the power of the test. A scatter plot with either partial or full coverage restorations in private dental of-
was produced for the graphical representation of the association be- fices during a specific time period.45-47,49 In 3 of the included stud-
tween SR and follow-up time (in months). Spearman’s rho correlation ies, the treatment protocols were conducted in a university setting
48,51,52
coefficient was computed for evaluating the strength of association. while 2 of them prοvided data from patients who received
Using SPSS v.15.0 (SPSS Inc., Chicago, Illinois) weighted smoothing treatment either at the authors’ private offices or at a university
curve using the Loess method 61 was also plotted on the correspond- clinic.51,53
ing scatter plot to verify the examined relationship. Generally, publi- Mean follow up periods varied significantly in the aforemen-
cation bias of various forms is almost assured, but fail-safe analyses tioned studies, ranging from 1 to 52 years. The total number of
cannot be trustworthily statistically tested and evaluated mainly due restorations inspected also varied significantly in the reviewed stud-
to the limited number of studies. MetaWin v.2.1 software was used ies, from 42 in the study of Reich et al51 to 16 858 in the study of
for performing the present analysis.60 Sulaiman et al49 In all studies included in this review restorations
were clinically examined at follow-up appointments.
idence to enhance the discussion. Angeletaki 2016 Systematic review Only partial
F -meta-analysis coverage
restorations
4 | R E S U LT S Roggendorf 2012 Prospective No additional
et al clinical study information
regarding the
4.1 | Study characteristics
survival rate of
The electronic and manual search of the literature provided an different restora-
tion types. No
initial bulk of 2849 studies. Further screening of the article titles
inlays included in
performed by the 2 principal investigators (GV, GK) resulted in 56 the study sample
potentially relevant studies. Independent evaluation at abstract level
Van Dijken 1999 Literature review Literature review
resulted in the exclusion of 35 articles, as they did not meet the in- et al
clusion criteria. Full-text screening resulted in inclusion of 9 out of Geurtsen 1999 Literature review Literature review
21 studies regarding the complications and survival rate of inlays/ et al
onlays versus full coverage restorations as is depicted in the flow Brodbeck 1997 Retrospective Author responded,
chart (Figure 2). The remaining 12 articles were excluded for differ- UR study but couldn’t
retrieve the article
ent reasons and were not analysed further (Table 2).64-75 Six out of
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912 VAGROPOULOU et al.
TA B L E 3 Random effects meta-analysis of survival rate (SR) differences between the inlays/onlays and full coverage restorations
according to the different types of restorations were not always statistically significant.
Number of Heckland et al supported that the survival rate of inlays/onlays was
Type of restoration studies Q df P 99.80%, while that of crowns was 98.40%.45 The authors however, did
not report on the main reasons of failure for both restoration groups.45 In
Inlay 3 0.4949 2 0.7808
the study of Donovan et al inlays and onlays demonstrated a survival rate
Onlay 6 0.1859 5 0.9993
of 95.30% and 97.00%, respectively, whereas crowns presented a survival
Crown 9 1.1006 8 0.9975
rate of 96.10%.46 Excellent results for the 5-year follow-up have been
Inlay-onlay 2 0.0012 1 0.9725
documented by Beier et al showing a 97.40% survival rate for crowns, and
Random effects ANOVA 98.90% for both onlays and inlays.48 The survival rates for the 10-year
Model df Q P P (Random)* follow-up are 90.00%, 92.40% and 96.80% for crowns, onlays and inlays,
respectively. However, for the 20-year follow-up the study of Beier et al
Between 3 0.2424 0.9705 0.585
demonstrated a 58.90% survival rate for crowns, as well as a 76.80% for
Within 16 1.7825 1.0000
inlays, respectively. That study also has showed that caries consisted the
Total 19 2.0249 1.0000
main reason for failure in all restoration types.48 Sulaiman et al reported
*P(Random): P value from randomisation test. a 98.85% survival rate for crowns and a 98.99% for inlays/onlays. The
most frequent complication was fracture of the restorative material.49 The
study of Fabbri et al demonstrated a survival rate of 93.5%-93.78% for
4.2 | Patient characteristics
ceramic onlays and 96.10%-98.10% for ceramic crowns.50 Clinical compli-
All articles included in this systematic review reported on patients cations concerning the crowns included mostly minor cohesive fractures
in need of either at least 2 of the compared study groups (inlays/ of the veneering ceramic, followed by crown chippings, core failures and
onlays vs full coverage restorations) or all of them. None of the finally loss of retention. Monolithic onlays mostly failed due to minor frac-
aforementioned publications reported any specific treatment pro- ture of the ceramic, followed by loss of retention.50
tocol received by patients prior to their main prosthodontic ther- On the contrary, in the study of Kelly et al full gold (FGCs) and ce-
apy. Two of the studies 48,50 have reported on oral and periodontal ramometal (CMCs) crowns presented the longest survival rates, while
health of the patients, as one of their inclusion criteria, while three cast onlays the lowest.47 Both types of full coverage restorations
48,50,51
of them included patients with parafunctional activities in demonstrated very similar survival rates for the first 5 years (95.40%
45,47,49,52
their study population. Four studies did not mention the for FGCs vs 93.60% for CMCs). A descending course of the survival
gender of the treated patients, while the remaining five 46,48,50,51,53 rate over the years was also demonstrated. The overall survival rate
included patients of both sexes. The age of patients ranged from 18 percentage for cast onlays for the 5-year period was 72.70%.
to 91 years, with no reports of patients with systematic diseases. A further analysis of the collected data revealed that the mean
survival rate of inlays was 90.89% (95% CI: 0.66-0.95), while for on-
lays and crowns the mean survival rate was 93.50% (95% CI: 0.86-
4.3 | Outcome characteristics
0.97) and 95.38% (95% CI: 0.89-0.98), respectively. For the fourth
The outcomes resulting from further examination and meta-analysis study group, consisting of both inlays and onlays, the survival rate was
of the included studies are presented in detail in Tables 3, 4, 5, 6 and 7. found to be 99.43% (95% CI: 0.99-1). The assessment of the 95% boot-
strap CI did not reveal a statistically significant difference between
the 4 groups, ie crowns, inlays, onlays, inlays/onlays. The latter group
4.4 | Primary outcomes
45,49
was formed as 2 studies supplied collectively the results for in-
4.4.1 | Survival rate lays and onlays. However, a wide confidence interval presented by the
group of inlays (95% CI: 0.66-0.95) was highlighted. A statistically sig-
As mentioned above, survival rate of the restoration is described as
nificant difference was demonstrated between the survival rate of all
the percentage of the restorations being in situ throughout a specific
observation period. This period varied between the studies included
TA B L E 4 Mean survival rate (SR) estimates according to the
in this systematic review. This fact, along with marked differences different types of restorations
in treatment protocols adopted by the authors of the included stud-
ies, as well as the variability in case selection, made the drawing of Type of Number of Bias Corrected 95%
restoration studies Mean SR CI
any conclusion as to the superiority of 1 type of restoration over the
other, difficult. Inlay 3 0.9089 0.6552-0.9491
TA B L E 6 Random effects meta-analysis of survival rate (SR) restoration. In this systematic review, failures were grouped as either
according to the different types of study design (prospective/ biological or technical.77 Biological complications included caries, en-
retrospective) dodontic treatment, tooth and/or root fracture and hypersensitivity.
Number of Technical failures included ceramic fracture, crack, core failure, chip-
Class studies Q df P ping, problems with marginal integrity and loss of retention.
4.5.5 | Means of isolation
Only 2 studies 50,51 mentioned that rubber dam was used during the
clinical procedures.
4.5.6 | Dropouts
Unfortunately, only 3 studies supplied data regarding the dropouts.
One of those studies reported dropouts at restoration level, stating
F I G U R E 3 Correlation between SR and follow-up time (in mo),
rho Spearmann (rho = −0.748, P < 0.001) [Colour figure can be that 10.00% of the crowns, and 31.57% of the onlays could not be
viewed at wileyonlinelibrary.com] re-evaluated.45 In contrast, the studies of Donovan et al. 46
and van
53
Dijken et al reported dropouts at patient level. In the first of these 2
studies 5.00% of the patients have not been re-evaluated, while in the
The assessment of the 95% bootstrap CI could not establish an second one 14.04% of patients did not come back for reassessment.
association between the kind of complications and different types of
restorations. Nevertheless, a relatively high failure rate due to caries
and ceramic fractures was noted. The latter was also recognised as
4.5.7 | Quality assessment
the predominant cause of failure by several authors.48,50,52 Considering the quality of evidence provided by the studies included
in this systematic review, the overall quality of evidence is low as
no randomised controlled trial (RCT), was identified for inclusion
4.5.2 | Evaluation criteria
(Figure 4).
All studies did not use the same criteria for restoration evaluation.
Three criteria have been identified. These included the USPHS, the
modified USPHS and the modified CDA. Donovan et al46 and Reich 5 | D I S CU S S I O N
et al51 used the USPHS criterion, while the last one also used the
modified USPHS criterion for the proximal contacts. The modified The main purpose of this review was to identify clinical studies
USPHS was also used by Barnes et al52 and van Dijken et al.53 Finally, in which crowns and inlays/onlays were used to restore damaged
Beier et al48 and Fabbri et al50 used the modified CDA. However, only teeth, and compare their biological and technical complications, as
Donovan et al and Beier et al specified which scale was considered well as their survival rates. Moreover, possible outcome differences
as a failure (Charlie and Delta).46,48 The rest of the authors did not between the 2 different treatment modalities (crowns vs inlays/on-
report any additional information for each type of evaluation criteria. lays) were also investigated. Therefore, a systematic search of pub-
lished literature was organised and carried out in order to identify
high-level evidence.
4.5.3 | Inclusion criteria
It was the intention of the authors this systematic review to be
Only 3 out of 9 studies reported on the necessary criteria a patient conducted in accordance with the guidelines of PRISMA40 and the
should fullfil in order to be included in the study. Beier et al48 re- Cochrane Collaboration’s tool for assessing risk of bias62 in randomised
50
quired periodontally healthy patients. Fabbri et al set good oral hy- trials. Nevertheless, a modification was considered necessary, as no
giene, vital and endododontically treated teeth and natural dentition RCT satisfying the inclusion criteria was found in the literature.
in the opposing arch, as their only requirements, while Reich et al51 A total of 9 observational studies were included in the analy-
included only extensively damaged teeth. sis, after a thorough electronic and hand search strategy were con-
ducted. It should be mentioned, however, that a great variation both
in the number of restorations evaluated and the follow-up periods
4.5.4 | Parafunctional habits
was identified. The biggest number of restorations was evaluated
Only 4 out of the 9 included studies commented on the parafunc- by Sulaiman et al49 who have reported on 16 858 units, while the
tional habits that the treated patients had. Specifically, van Dijken longest evaluation period was accomplished by Donovan et al46 who
53
et al mentioned that bruxers were included in their study, without reported for a period of up to 52 years. As it is evident, patients in
VAGROPOULOU et al. |
915
ipating in that study. A systematic review on bruxism and prosthetic and bulk fracture.85 The studies of both Sulaiman et al and Fabbri
treatment by Johansson et al has shown that bruxism is associated et al have demonstrated very high survival rates, ranging from
with an increased rate of mechanical and technical complications. 82 93.50% to 98.99%.49,50 In these 2 studies, the most frequent com-
Another important fact about the study of Beier et al is that zinc plications were not biological as those in the study of Beier et al.48
phosphate luting agent was used for the majority of the resto- On the contrary, some technical complications were encountered.
rations. 48
A prospective clinical study 83
has shown that there are These included cohesive factures and chippings. An interesting fact
no statistically significant differences in the outcome of restorations is that in the study of Fabbri et al layered crowns presented a higher
luted with resin and zinc phosphate cements. However, zinc phos- survival rate (98.10%) than the monolithic ones (96.10%) 50 It should
phate when compared with resin cements, demonstrates no chemi- be mentioned however that, these rates are quite similar and prob-
cal or micromechanical bonding, while it has lower compressive and ably not statistically significant different. Nevertheless, it should
tensile strengths, as well as high solubility in oral fluids.84 The latter be emphasised that the literature suggests that monolithic crowns
disadvantage of zinc phosphate cement may partially explain the present better mechanical properties than the layered ones. Several
fact that secondary caries was the main reason of biological com- studies have demonstrated that the flexural strength of veneering
failures also determine the survival of the restorations. When single sponding value for a core material exceeds 450 MPa.86-88 Moreover,
|
916 VAGROPOULOU et al.
a mismatch between the coefficients of thermal expansion of the Another important point, which is not addressed by several au-
veneering and the core material may cause stress fields throughout thors, is the inclusion criteria. Only 3 out of the 9 studies of this sys-
the restoration, resulting in chipping or bulk fracture. Unsupported tematic review reported on this issue.48,50,51 It should be mentioned
porcelain, due to improper core design, can also be one of the rea- however that, the authors of these 3 studies did not clearly define
sons of fracture, as research has shown that restorations supported the inclusion criteria. Terms like good oral hygiene and extensively
by anatomically correct cores presented smaller fatigue-c aused damaged teeth are used by the authors, with no further explanation.
chippings than cores with a flat design. Furthermore, restorations Nevertheless, inclusion criteria are very important if consistency of
with anatomical cores could tolerate higher stresses than the non- findings among similar studies is to be accomplished. Inclusion criteria
anatomical ones.89 Other parameters, including prepared tooth’s have to have a good validity and reliability in order to assist minimising
axial wall height, thicknesses of core and veneering materials, ce- random error, misclassification of exposures and outcomes, selection
ment thickness and modulus of elasticity, as well as loading con- bias and confounding factors. This last variable is very important in
ditions, may influence the restoration’s longevity.90,91 The study of observational studies, as inclusion criteria can be used to control it, in
Kelly et al has demonstrated that full coverage restorations, either the form of specification or restriction and matching. In this way im-
metal ceramic or full gold, present a higher survival rate than cast balances between comparison groups are removed or homogenised.97
47
onlays. This is an interesting finding, as onlays are usually placed Although parafunctional habits and especially bruxism is consid-
on teeth which are less damaged than those restored with a full cov- ered as a major factor for tooth wear and prostheses failures, only 4
erage restoration. It should be mentioned however that the decision out of the 9 selected studies commented on this issue.48,50,51,53 Of
as to which type of restoration will be used is also a matter of ex- those, only 2 studies supplied enough details regarding the number of
perience, clinical judgement and skills.80 Unfortunately, the biolog- patients who were bruxers.48,50 However, no information is supplied
ical and technical complications leading to failures have not been regarding the number of failing units in bruxers. As already mentioned
included in that article by the authors. Therefore, only assumptions in the results, only the study of Reich et al identified an onlay fracture
can be made for that purpose. The fact that the preparation of an due to bruxism.51 Although a direct relationship between bruxism and
onlay is more technically demanding when compared with that of technical or biological complications has not been established in the
a full coverage restoration may be one reason.9 The lower survival past, there are some studies which have noted a possible association
rate may also be attributed to the fact that onlays have a longer between them.98,99 Therefore, it would be beneficial if the authors of
finishing line than the corresponding full coverage restorations. the selected studies had reported on incidences of failures possibly
Therefore, there is a bigger chance for recurrent decay. Finally, it has associated with bruxism. It has been discussed in the literature that
been claimed that onlays are mechanically inferior when compared probably metal and metal-ceramic restorations are the safest choices
with full coverage restorations, due to their incomplete ring design.9 for patients with parafunctional habits.100,101 Monolithic materials—ei-
A comparison between full gold, metal-ceramic and all-ceramic res- ther zirconia or lithium disilicate—which exhibit high flexural strength,
torations cannot be performed from this study as the majority of can probably be used for those patients, as well.102,103 The materials
the restorations were metal-ceramic (65.63%) followed by full gold used in the studies selected for this systematic review included gold,
(28.79%). All-ceramic restorations represented only 5.57%. metal-ceramic and all-ceramic. These studies were published between
Different criteria for the evaluation of restorations have been ad- 2004 and 2015. Therefore, different types of ceramics (feldspathic,
opted by the authors of the studies included in this systematic review. leucite reinforced, lithium disilicate) have been used by the authors.
A common problem is that usually there is a perceptual and a judge- Moreover, ceramics are continuously improving, as a lot of research is
mental variation among evaluators of different studies. Furthermore, being placed towards that direction. In a review on the performance of
the procedures used for evaluation and use of other supplemental aids dental ceramics, Rekow et al have pointed out that not only the prop-
vary. Therefore, a direct comparison of the results is almost impossi- erties change, as the materials improve, but also the fabrication condi-
ble. Six out of the 9 included studies referred to the evaluation criteria tions may differ. In addition, the handling conditions during the clinical
used. These included both the USPHS and the CDA. The first one was procedures may vary widely. All these parameters have as a result a
developed by Cvar and Ryge in 1971, in order to be used for the clinical difficulty in drawing conclusions or ensuring the equivalence of suc-
evaluation of dental restorative materials.92 It was intended to be used cess even within a single class of ceramic.104 Another parameter which
by the United States Public Health Service (USPHS). The CDA system is important and no information is given by the authors is that of the
is a variation of the system proposed by Cvar and Ryge, and it has been core material. An in vitro study has shown that full coverage ceramic
adopted by the California Dental Association (CDA).93 These criteria restorations have a high probability of fracture if they are cemented
evaluate colour matching, anatomic contour, surface texture, cavosur- on cores made of resin-modified glass-ionomer materials, as they lack
face marginal discoloration, marginal integrity, secondary caries and rigidity and may present a hygroscopic expansion.105
94
gross fracture. Both the USPHS and the CDA systems are based on The luting agents used in the selected studies included zinc phos-
an ordinal scale, and evaluate the restorations as “acceptable” or “not phate, flowable composite resin, chemically cure and dual cure resin
acceptable.” For that reason, modified criteria have been developed, in cements. Marked cement dissolution is seldom observed, as all luting
order to complement the 2 original systems, for a better evaluation of agents comply with ADA or ISO standards. However, inadequate mois-
the characteristics of indirect and direct restorations.95,96 ture control and presence of saliva during the cementation procedures
VAGROPOULOU et al. |
917
can adversely affect cements like zinc phosphate or glass ionomer, re- • Recurrent decay, endodontic reasons and tooth fractures were
106,107
sulting in ineffective marginal seal and recurrent decay. Although the most frequent biologic complications.
resin-based cements are not affected by moisture, their handling is also • Ceramic fractures and core failures were the most frequent pros-
sensitive. If all precautions are taken these cements resist wear and sol- thetic complications.
ubility much better than conventional cements.108 It should be men- • The overall quality of evidence of the 9 studies was low. Due
tioned however that, disintegration of luting agents may also start under to the heterogeneity of the included studies no meaningful
restorations deformed by occlusal loading, leading to cement fracture comparison could be made between types or restoration of
after crack propagation.109 Although gold cast and metal ceramic res- materials.
torations can be luted with any cement, all ceramic restorations should
be luted with resin cements, as literature has shown that acid etched all
ceramic restorations cemented with resin composite present a signifi- AC K N OW L E D G M E N T S
cantly better survival function than those cemented with either glass
ionomer or zinc phosphate cements. The same clinical study has shown No ethical approval was obtained as this research study did not
that differences between all ceramic restorations luted with glass iono- involve participation of any humans or animals. No funding was
mer or zinc phosphate agents were not significant. 110 obtained from any institution or agency. This work was supported
As already mentioned in the results section all but 2 studies solely by its authors. The authors have stated explicitly that there
46,49
provided information about the location of the restorations. are no conflicts of interest in connection with this article.
Unfortunately, the authors of all papers did not provide information
about the location of the restorations which failed. This is a very ORCID
important issue, as the literature suggests that both biological and
technical complications may be associated with the location of the Konstantinos Michalakis http://orcid.org/0000-0001-5891-4823
restorations. A clinical study of 88 direct and indirect composite
resin restorations followed for a period of 2 years has shown that
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